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Inspection ID Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 Phone: (404)562-9424 EPA Well ID#: F L S 1 1 3 0 0 5 8 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 0 9 Page 1 Of 2 Inspector(s): _____C_a_r_o_l_C__h_e_n____________________ (lead), ______C_a__rl_a__F_o_y_____________________ Start Time: _3_:_2_0__p__m__ ____________________________________ , _______________________________________ End Time: _3_:_2_2__p_m___ Facility Contact Information Facility Name:__M__a_v_e_r_i_c_k__N_a_t_u_r_a__l _R_e_s__o_u_r_c_e_s_,__L_L_C____________(B__r_e_it_b_u__r_n_O__p_e_r_a__ti_n_g_,__L_P_)____________________ Street Address:_5__4_1__5__O_i_l _P_l_a_n_t__R_d_______________________________________________________________________ City: _____J_a_y________________________ County: ___S__a_n_t_a__R_o__s_a_________________ State:___F_L____ Zip: _3__2_5__6_5__ Nature of Business: _____o_i_l _a_n_d__g_a__s_p__ro__d_u_c_t_i_o_n___________________________________________________________ Facility Owner/Operator: _M__a_v_e__r_ic_k__N__a_t_u_r_a_l_R__e_s_o_u__rc_e__s_,_L_L_C________________ Phone: _8__5_0__-6__7_5_-_1_7__0_2_________ Email: ________________________________________________________________________________________________ Facility Contact (if different): __A_l__J_o_n_e_s_,__P_l_a_n_t__S_u_p_e__r_in_t_e_n__d_e_n__t _______________ Phone: __2_5_1__-2__2_7__-3__3_1_9_________ O/O Mailing Address: ___5_4__1_5__O__il_P__la__n_t_R__d________________________________________________________________ City: ______J_a_y_______________________ County: ____S__a_n_t_a__R_o__s_a________________ State:__F_L_____ Zip: __3_2__5_6_5__ Well Data from File Well Name & #: __S__t.__R_e_g_i_s__S_W__D__S__#_9_-_6______________________A__P_I_N__o_._0__9_-_1_1_3__-2__0_2__0_6_____P_A__N__o_._3__1_1__6_4_3___ Well Type (see table): __E_n__h_a_n_c__e_d__O_i_l_R_e__c_o_v_e_r_y__(E__O_R__)_______________ State Permit: _________O_G____1__0_9_1_________ Latitude (N): ______3_0__.9__5_9__4_5_7__________ Longitude (W): _______-_8_7_._1_9__2_0__7_2______ Elevation (ft): ____________ Injection Method (check applicable): Casing Injector; X Tubing & Packer; Cemented Injection Tubing PBTD: 6800' surface casing 9 5/8" at 2315' Other: __________________________________________________________________ Total Depth (ft): __6__9__0_0__'_ at 6100' Inner Casing Size (in): 7_"_a_t_6__8_4_8'Tubing Size (in):4__1_/_2__"____ Packer Depth (ft): _6__1_0__0__' Inj. Zone: Open Hole; X Perforated; Top(ft) _6__3__8_0__' Bottom(ft): __6__7_9__8__' __ Max. Injection Pressure (psig): 1_7__3_1__p_s_i Field Measurements and Observations Latitude (N): _____3_0__.9__5_9__4_3_8___________ Longitude (W): ____-8__7_._1_9__2_0_1__3_________ Elevation (ft): ____________ EPA GPS ID: _S_7__5_3__3_2_ Well Status (see table): ____T_A____ If not Active, Reported Date Last Active: __2__/_1_4__/_2_0__1_2_____ Nature of Injected Fluid(s) if any: __________________________________________________________________________ General Condition of the Well Site: _________________________________________________________________________ _____________________________________________________________________________________________________ Notes & Comments (include discrepancies from database values): ______________________________________________________ _s_ig_n__: _H_a__z_a_r_d_o_u__s_O__p_e_r_a__ti_o_n_._._.K__e_e_p__O__u_t_______________________________________________________________ _T_h_i_s__is__a_n__i_n_a_c_t_i_v_e__w_e_l_l._______________________________________T_u_b__in_g__g_a_u_g_e__: _________0__p_s_i_____________ _T_h_e__re__i_s__a_l_a_r_g_e__p_o__o_l_o_f__fl_u_i_d_s__ju__s_t_b_e__h_i_n_d__th__e__w_e_l_l_. ___________P_r_o_d_u_c_t_i_o_n__g_a_u_g_e_:_____0__p_s__i _____________ ______________________________________________________________S_u_r_f_a_c_e__g_a_u_g_e_:________0__p__s_i _____________ ______________________________________________________________F_l_o_w__li_n_e__g_a_u_g_e_:_________________________ _____________________________________________________________________________________________________ See reverse for additional observations, comments and photo log UIC Inspector UIC Inspector Name:______C__a_r_o_l _C_h_e_n________________________________ Name: ______________________________________________ Signature: _C_A__R__O__L__C__H_E__N_______D_a_te_: _20_2_4._06_.2_0_2_1:_40_:4_5_-0_4_'0_0'___ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18 Inspection ID Field Measurements and Observations (Cont.) Class I and II Well Inspection Form US Environmental Protection Agency - Region 4 Underground Injection Control Program 61 Forsyth Street SW, MC 9T25, Atlanta, Georgia, 30303 Phone: (404)562-9424 EPA Well ID#: F L S 1 1 3 0 0 5 8 Year-Month-Day: 2 0 2 4 - 0 4 - 3 0 EPA Permit # (or RA): F L I 0 0 0 9 Page 2 Of 2 (Cont) ________________________________________________________________________________________________ ______S__t.__R_e_g__is__S_W__D__S__#_9_-_6__________S_t_a_t_e__P_e__rm__i_t_N__o_._O__G____1_0_9__1__________A__P_I_N__o_._0__9_-_1_1_3__-2__0_2__0_6_______ _____________________________________________________________________________________________________ ________________________________P_e__rf_o_r_a_t_i_o_n_s__(_T_u_s_c_a__lo__o_s_a__F_o_r_m__a_t_i_o_n_)_:________________________________ ______________________________________________6_3__8_0_'_t_o__6_6__1_0__' _(4__S__P_F_)_________________________________ ______________________________________________6_6_9__8_'_t_o__6_7__9_8__' _(2__S__P_F_)_________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Photo Log Photographer:______C_a__rl_a__F_o_y________________________EPA Camera ID: _______S__7_5__3_3_2________________________ Photo ID: __R__IM__G__0_1__6_1_____Time: __3__:2__0__p_m___ Lat (N): ___3_0__.9__5_9_3__3_________ Long (W) ___-8__7_._1_9__2_0_3__2________ Description: _i_n_j_e_c_t_io__n__w_e_l_l_, _id__e_n_t_if_i_c_a_t_io__n__s_ig_n__,_p_o__o_l_o_f__fl_u_i_d_s_,_s_i_g_n__o_f__H_a_z_a__r_d_o_u_s__O__p_e_r_a_t_i_o_n_._.._K_e__e_p__O_u__t__ Photo ID: ___R_I_M__G_0__1_6______Time: ___3_:_2_1__p_m___ Lat (N): ___3_0__.9__5_9__4_3_8________ Long (W) ___-_8_7_._1_9__2_0__1_3________ Description: __p_r_o_d_u__c_ti_o_n__a_n__d__s_u_r_f_a_c_e__g_a_u__g_e_s___________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ Photo ID: _________________Time: ____________ Lat (N): _____________________ Long (W) ______________________ Description: ___________________________________________________________________________________________ UIC Inspector UIC Inspector Name:_____C_a_r_o_l_C__h_e_n_________________________________ Name: ______________________________________________ Signature: _C_A__R__O_L__C__H__E_N________D_a_te_: 2_0_24_.0_6_.20_2_1_:4_1:_11_-0_4_'0_0'____ Signature: ___________________________________________ Digitally signed by CAROL CHEN Version 2018-04-18